Guidelines by society of the American Gastrointestinal and Endoscopic Surgeons. (USA)
Surgical techniques
Guideline 7: diagnostic laparoscopy is safe and effective when used selectively in the workup and treatment of acute abdominal processes in pregnancy (moderate; strong).
Diagnostic laparoscopy provides direct visualization of intra-abdominal organs. While not enough data are available to recommend this as a primary diagnostic approach in the pregnant patient, it is a reasonable alternative to radiologic imaging. The benefits of operative exploration are avoidance of ionizing radiation, diagnostic accuracy, and the capability to treat a surgical problem at the time of diagnosis.
Furthermore, it has been shown that laparoscopy can be performed safely during any trimester of pregnancy with minimal morbidity to the fetus and mother [39-51].
Patient selection – Pre-operative decision-making
Guideline 8: laparoscopic treatment of acute abdominal disease has the same indications in pregnant and non-pregnant patients (moderate; strong).
Once the decision to operate has been made, the surgical approach (laparotomy versus laparoscopy) should be determined based on the skills of the surgeon and the availability of the appropriate staff and equipment. An appropriate discussion with the patient regarding the risks and benefits of surgical intervention should be undertaken. Benefits of laparoscopy during pregnancy appear similar to those benefits in non-pregnant patients including less postoperative pain, less postoperative ileus; decreased length of hospital stays and faster returns to work [40, 45, 52-55].
Laparoscopy and trimester of pregnancy
Guideline 9: laparoscopy can be safely performed during any trimester of pregnancy (moderate; strong).
Operative intervention may be performed in any trimester of pregnancy. Historical recommendations were to delay surgery until the second trimester in order to reduce the rates of spontaneous abortion and preterm labor [56]. Recent literature has shown that pregnant patients may undergo laparoscopic surgery safely during any trimester without any increased risk to the mother or fetus [39, 40, 55, 57-60]. Postponing necessary operations until after parturition may, in some cases, increase the rates of complications for both mother and fetus [57, 61-63].
It has been suggested that the gestational age limit for successful completion of laparoscopic surgery during pregnancy is 26 to 28 weeks [44]. This has been refuted by several studies in which laparoscopic cholecystectomy and appendectomy have been successfully performed late in the third trimester [58, 60, 64, 65].
Although laparoscopy can be performed safely in pregnancy with good fetal and maternal outcomes, the long-term effects to the children have not been well studied. One recent study evaluated eleven children from one to eight years and found no growth or developmental delay [51].
Treatment
There are many advantages of laparoscopy in the pregnant patient including: decreased fetal respiratory depression due to diminished postoperative narcotic requirements [45, 66-68], lower risk of wound complications [66, 69, 70], diminished postoperative maternal hypoventilation [66, 67], shorter hospital stays, and decreased risk of thromboembolic events. The improved visualization in laparoscopy may reduce the risk of uterine irritability by decreasing the need for uterine manipulation [71]. Decreased uterine irritability results in lower rates of spontaneous abortion and preterm delivery [72].
Patient positioning
Guideline 10: gravid patients should be placed in the left lateral decubitus position to minimize compression of the vena cava (moderate; strong).
When the pregnant patient is placed in a supine position, the gravid uterus places pressure on the inferior vena cava resulting in decreased venous return to the heart. This decrease in venous return results in significant reduction in cardiac output with concomitant maternal hypotension, and decreased placental perfusion during surgery [73-75]. Placing the patient in a left lateral decubitus position will shift the uterus off the vena cava improving venous return and cardiac output [73, 74].
Initial port placement
Guideline 11: initial abdominal access can be safely accomplished with an open (Hasson) technique, verses needle or optical trocar, if the location is adjusted according to fundal height and previous incisions (moderate; strong).
There has been much debate regarding abdominal access in the pregnant patient with preferences toward either a Hasson technique or Veress needle. The concern for use of the veress needle has largely been based on concerns for injury to the uterus or other intra-abdominal organs [76, 77]. Because the intra-abdominal domain is altered during the second and third trimester initially accessing the abdomen via a subcostal approach has been recommended [58, 60, 64, 71]. If the site of initial abdominal access is adjusted according to fundal height and the abdominal wall is elevated during insertion, both the Hassan technique and veress needle can be safely and effectively used [58, 60, 78].
It has also been recommended that trocar placement be altered from the standard configuration to account for the increased size of the uterus [79, 80]. Ultrasound guided trocar placement has been described in the literature as an additional safeguard to avoid uterine injury [81].
Insufflation pressure
Guideline 12: co2 insufflation of 10-15 mmhg can be safely used for laparoscopy in the pregnant patient (moderate; strong).
The potential for adverse consequences from co2 insufflation in the pregnant patient has led to apprehension over its use. As such, some authors advocate gasless laparoscopy in pregnant patients, but this technique not been widely adopted [82-89].
The pregnant patient’s diaphragm is upwardly displaced by the growing fetus, which results in decreased residual lung volume and functional residual capacity [90]. Upward displacement of the diaphragm by pneumoperitoneum is more worrisome in a pregnant patient with existing restrictive pulmonary physiology. Some have recommended intra-abdominal insufflation pressures be maintained at less than 12 mmhg to avoid worsening pulmonary physiology in gravid women [80, 91]. Others have argued that insufflation less than 12 mmhg may not provide adequate visualization of the intra-abdominal cavity [58, 60]. Pressures of 15 mmhg have been used during laparoscopy in pregnant patients without increasing adverse outcomes to the patient or her fetus [58, 60].
Because co2 exchange occurs with intra-peritoneal insufflation there has been concern for deleterious effects to the fetus from pneumoperitoneum. Some animal studies have confirmed fetal acidosis with associated tachycardia, hypertension and Hypercapnia during co2 pneumoperitoneum [92-94], while other animal studies contradict these findings [95]. There are no data showing detrimental effects to human fetuses from co2 pneumoperitoneum [44].
Intra-operative CO2 monitoring
Guideline 13: intraoperative co2 monitoring by Capnography should be used during laparoscopy in the pregnant patient (moderate; strong).
Fetal acidosis and associated fetal instability in co2 pneumoperitoneum have been documented in animal studies, though no long-term effects from these changes have been identified [92-94, 96]. Fetal acidosis with insufflation has not been documented in the human fetus, but concerns over potential detrimental effects of acidosis have led to the recommendation of maternal co2 monitoring [97, 98]. Initially, there was debate over maternal blood gas monitoring of arterial carbon dioxide (paco2) versus end-tidal carbon dioxide (etco2) monitoring, but the less invasive Capnography has been demonstrated to adequately reflect maternal acid-base status in humans [99]. Several large studies have documented the safety and efficacy of etco2 measurements in pregnant women [44, 58, 60] making routine blood gas monitoring unnecessary.
Venous Thromboembolic (VTE) Prophylaxis
Guideline 14: intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (moderate; strong).
Pregnancy is a Hypercoagulable state with a 0.1-0.2% incidence of deep venous thrombosis [100]. Co2 pneumoperitoneum may increase the risk of deep venous thrombosis by predisposing to venous stasis. Insufflation of 12 mmhg causes a significant decrease in blood flow that cannot be completely reversed with intermittent pneumatic compression devices or intermittent electric calf stimulators [101].
Although there is little research on prophylaxis for deep venous thrombosis in the pregnant patient, general principles for laparoscopic surgery apply. Because of the increased risk of thrombosis, prophylaxis with pneumatic compression devices both intra-operatively and postoperatively and early postoperative ambulation are recommended. There are no data regarding use of unfractionated or low molecular weight heparin for prophylaxis in pregnant patients undergoing laparoscopy, though its use has been suggested in patients undergoing extended major operations [102]. In patients who require anticoagulation during pregnancy, heparin has proven safe and is the agent of choice [103].
Gallbladder disease
Guideline 15: laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease, regardless of trimester (moderate; strong).
In the past non-operative management of symptomatic Cholelithiasis in pregnancy has been recommended [61, 104-106]. At present early surgical management is the treatment of choice. Early surgical management of gravid patients with symptomatic gallstones is supported by data showing recurrent symptoms in 92% of patients managed non-operatively who present in the first trimester, 64% who present in the second trimester, and 44% who present in the third trimester [107, 108]. This delay in surgical management results in increased rates of hospitalizations, spontaneous abortions, preterm labor, and preterm delivery compared to those undergoing cholecystectomy [39, 40, 52, and 88-91.
Altogether, non-operative management of symptomatic gallstones in gravid patients results in recurrent symptoms in more than 50% of patients, and 23% of such patients develop acute Cholecystitis or gallstone pancreatitis [57]. Gallstone pancreatitis results in fetal loss in 10% to 60% of pregnant patients [109, 110].
The significant morbidity and mortality associated with untreated gallbladder disease in the gravid patient favor surgical treatment. Laparoscopic cholecystectomy is preferred because of the salutary outcomes and favorable side-effect profile [59]. There have been no reports of fetal demise for laparoscopic cholecystectomy performed during the first and second trimesters [111]. Furthermore, decreased rates of spontaneous abortion and preterm labor have been reported in laparoscopic cholecystectomy when compared to laparotomy [112].
Laparoscopic Appendectomy
Guideline 17: laparoscopic appendectomy may be performed safely in pregnant patients with appendicitis (moderate; strong).
The laparoscopic approach is the preferred treatment for pregnant patients with presumed appendicitis [122], and the preponderance of studies have shown the technique to be safe and effective [58, 60, 123-129]. These retrospective series have shown very low rates of pre-term delivery and, in most series, no reports of fetal demise.
Accurate and timely diagnosis of appendicitis in the gravid patient may minimize the risk of fetal loss and optimize outcomes. In some circumstances clinical findings may be sufficient for diagnosis. When the diagnosis remains uncertain, prompt ultrasound, CT, or MRI are useful adjuncts to more accurate diagnosis of appendicitis and decrease the rate of negative laparoscopy. However the false negative rates of CT and MRI studies have yet to be fully evaluated in the gravid patient, and some hospitals may not have immediate access to these radiologic modalities.
The published data overwhelmingly attest to the safety of Laparoscopic Appendectomy in the gravid patient, but one recent study describes a higher risk for laparoscopy compared to Laparotomy [130]. This population-based study showed an odds ratio of 2.3 for fetal loss in laparoscopy compared to conventional surgery for appendicitis. This single study does not contraindicate laparoscopic appendectomy in pregnant patients, but does illuminate a need for further research on the subject. Unless future studies bolster the above observational data, laparoscopic appendectomy remains the treatment of choice for pregnant patients.
Obstetrical consultation
Guideline 22: obstetric consultation can be obtained pre- and/or postoperatively based on the severity of the patient’s disease, gestational age, and availability of the consultant (moderate; strong).
Maternal and fetal monitoring should be part of any pregnant patient’s care and continue throughout her hospitalization, but the timing of a formal obstetric consultation will vary based on availability of the consultant and the severity of the patient’s condition. Delaying the treatment of an acute abdominal process to obtain such a consultation should be avoided as treatment delay may increase the risk of morbidity and mortality to the mother and fetus [181].
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